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Chapter 31: Child Psychiatry
Pathology and Laboratory
Examination
Although no single specific laboratory test is used to make
a diagnosis, many children with reactive attachment disor-
der have disturbances of growth and development. Thus,
establishing a growth curve and examining the progression
of developmental milestones may be helpful in determining
whether associated phenomena, such as failure to thrive, are
present.
Differential Diagnosis
The differential diagnosis of reactive attachment disorder and
disinhibited social engagement disorder must take into account
that many other psychiatric disorders may arise in conjunction
with maltreatment, including depressive disorders, anxiety dis-
orders, and posttraumatic stress disorders. Psychiatric disor-
ders to consider in the differential diagnosis include language
disorders, autism spectrum disorder, intellectual disability, and
metabolic syndromes. Children with autism spectrum disorders
are typically well nourished and of age-appropriate size and
weight, and are generally alert and active, despite their impair-
ments in reciprocal social interactions. Significant intellectual
disability is often present in children with autism spectrum dis-
order, whereas when intellectual disability occurs with reactive
attachment disorder or disinhibited social engagement disorder,
it is generally relatively mild. Children with disinhibited social
engagement disorder often show comorbid attention-deficit/
hyperactivity disorder, posttraumatic stress disorder, and lan-
guage disorder or delay. Furthermore, children with disinhib-
ited social engagement disorder symptoms may have complex
neuropsychiatric problems.
Course and Prognosis
Most of the data available on the natural course of children with
reactive attachment disorder and disinhibited social engage-
ment disorder come from follow-up studies of children in
residential facilities with histories of serious neglect. Findings
from these studies suggest that children with reactive attach-
ment disorder, who are later adopted into caring environments,
improve in their attachment behaviors and may normalize over
time. Children with disinhibited social engagement disorder,
however, appear to have more difficulty developing attach-
ments to new caregivers. Children with disinhibited social
engagement disorder who exhibit indiscriminate social behav-
ior also tend to have poor peer relationships. The prognosis
for children with reactive attachment disorder and disinhib-
ited social engagement disorder is influenced by the duration
and severity of the neglect and the degree of impairment that
results. Constitutional and nutritional factors interact in chil-
dren, who may either respond resiliently to treatment or con-
tinue to fail to thrive. After a pathological caregiving situation
has been recognized, the amount of treatment and rehabilita-
tion that the family receives affects the child. Children who
have multiple problems stemming from pathogenic caregiving
may recover physically faster and more completely than they
do emotionally.
Treatment
The first consideration in treating reactive attachment disorder
or disinhibited social engagement disorder is a child’s safety.
Thus, the management of these disorders must begin with a
comprehensive assessment of the current level of safety and
adequate caregiving. When there is suspicion of maltreatment
persisting in the home, the first decision is often whether to
hospitalize the child or to attempt treatment while the child
remains in the home. If neglect, or emotional, physical, or
sexual abuse is suspected, legally, such must be reported to the
appropriate law enforcement and child protective services in
the area. The child’s physical and emotional state and the level
of pathological caregiving determine the therapeutic strategy.
A determination must be made regarding the nutritional sta-
tus of the child and the presence of ongoing physical abuse
or threat. Hospitalization is necessary for children with mal-
nourishment. Along with an assessment of the child’s physical
well-being, an evaluation of the child’s emotional condition is
important. Immediate intervention must address the parents’
awareness and capacity to participate in altering the injurious
patterns that have heretofore ensued. The treatment team must
begin to improve the unsatisfactory relationship between care-
giver and child. This usually requires extensive and intensive
intervention and education with the mother or with both par-
ents when possible.
In one study, parents of 120 children between 11.7 months
and 31.9 months, identified as being at risk for neglect, were
randomly assigned to an intervention for at-risk parents called
Attachment and Biobehavioral Catch-up (ABC) or to a control
intervention. The ABC intervention was designed to decrease
frightening behavior toward the infant by parents, and to
increase sensitive and nurturing interactions between parents
and infant. The intervention was manualized so that parents
were specifically guided in how to provide those interactions
with their infants. Children were evaluated after 10 sessions,
and the 60 children who received the ABC intervention showed
significantly lower rates of disorganized attachment (32%), and
higher rates of secure attachment (52%) compared to those
who received the control intervention (disorganized attachment
57%; secure attachment 33%). The authors concluded that
parental nurturance and sensitivity can be enhanced by a com-
prehensive and explicit intervention such as the ABC interven-
tion, and significant improvements in attachment behaviors can
be measured in young children after 10 sessions.
The caregiver–child relationship is the basis of the assess-
ment of reactive attachment disorder and disinhibited social
engagement disorder symptoms, and the substrate from which
to modify attachment behaviors. Structured observations allow
a clinician to determine the range of attachment behaviors
established with various family members. The clinician may
work closely with the caregiver and the child to facilitate greater
sensitivity in their interactions. Three basic psychotherapeutic
modalities are helpful in promoting positive bonds between
children and caregiver. First, a clinician can target the caregiver
to promote positive interaction with a child who does not yet
have the repertoire to respond positively. Second, a clinician can
work with the child and the caregiver together as a dyad to advo-
cate for practicing appropriate positive reinforcement for each
other. Through the use of videotapes, parent–child interactions
